肝移植术后早期急性排斥反应的微透析监测

Continuous Graft Monitoring of Early Acute Rejection with Microdialysis after Orthotopic Liver Transplantation

目的对移植肝术后早期代谢及并发症进行实时连续的床旁监测.方法在12例肝移植患者手术结束前,在肝镰状韧带水平通过Ⅳ段插入Ⅴ段或Ⅷ段植入微透析导管,关腹,然后在皮下脂肪植入对照管.术后,每小时将微量收集瓶里回收的透析液在微透析分析仪里进行检测,通过测定透析液中葡萄糖、丙酮酸、甘油和乳酸的浓度来研究移植肝的代谢情况,同时对患者进行常规的监测和临床观察;监测持续到患者离开监护室,约5～7d,并在患者出院后每隔1个月进行随访.结果 (1)12例患者中有5例出现移植肝孤立性甘油水平升高(术后早期移植肝出现甘油显著增高而乳酸/丙酮酸比值稳定在低水平);(2)肝组织和皮下参照组织:微透析监测期间肝组织内甘油、乳酸/丙酮酸比值均大于皮下参照组织,而葡萄糖、乳酸、丙酮酸小于皮下参照组织(P<0.05);(3)多元线性回归分析移植肝的四项指标(葡萄糖、乳酸、丙酮酸和甘油)中甘油对丙氨酸转氨酶(ALT)和天门冬氨酸转氨酶(AST)有明显贡献,回归方程分别为ALT=93.83+0.68Glycerol(P<0.05),AST=-216.26+0.60Glycerol(P<0.05).结论 (1)微透析技术是一种微创安全的操作;(2)移植肝甘油水平与肝脏酶学(ALT、AST)有一定的相关性.在排除全身的缺血缺氧因素外,术后早期甘油升高预示移植肝肝细胞受损;(3)术后早期移植肝出现孤立性甘油升高,预示移植肝早期的排斥反应并发症.

Objective To observe early liver metabolism changes （glucose,lactate,glycerol,pyruvate） and prognosis of early acute rejection complication at bedside by continuous graft monitoring with microdialysis in patients with orthotopic transplantation.Methods At the end of the operation a microdialysis catheter was placed in segment Ⅳ in the direction of segment Ⅷ at the level of falciform ligament of graft.A reference catheter was placed simultaneously in the subcutaneous adipose tissue after abdominal closure. Consecutive serial samples were collected at 1-hour interval after the operation.Glucose,lactate,pyruvate and glycerol concentrations were measured.Meanwhile,some routine examinations were observed continually. Results （1） Five cases of twelve patients with liver transplantation were observed a significantly isolated elevation of glycerol,a significantly higher level of glycerol emerging,while lactate/pyruvate ratio stabilizing at a low level.（2） During the microdialysis monitoring,the level of liver＇s glycerol,lactate/pyruvate ratio was greater than the subcutaneous＇s,while the level of liver＇s glucose,lactate and pyruvate were less than the subcutaneous＇s （P 0.05）. （3） Regression equation indicated the mean level of glycerol was an important factor to the mean level of liver enzymes （ALT,AST）,the regression equations were ALT = 93.83 ＋0.68 Glycerol,AST =-216.26 ＋0.60 Glycerol respectively.Conclusions （1） The procedure of microdialysis is easy to perform and safe; （2） There is a certain relevance between the level of glycerol and enzyme of the graft. Therefore,the increase of the level of graft glycerol,excluding factors of system,can be used as a symbol of liver cells damage; （3） In the early stage of post-operation,the isolated elevation of glycerol will predict acute rejection complications of the graft.